| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
2,315 |
2,203 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,863 |
1,774 |
$52K |
| D1110 |
Prophylaxis - adult |
404 |
392 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
66 |
$17K |
| D1120 |
Prophylaxis - child |
352 |
346 |
$16K |
| D1351 |
Sealant - per tooth |
279 |
90 |
$9K |
| D0603 |
|
1,325 |
1,298 |
$9K |
| D0274 |
Bitewings - four radiographic images |
229 |
221 |
$8K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
14 |
$809.04 |
| D1310 |
|
12 |
12 |
$539.27 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$415.79 |
| D1330 |
|
12 |
12 |
$332.84 |
| D0602 |
|
29 |
29 |
$269.57 |
| D1999 |
|
18 |
15 |
$21.25 |